SSallP'IfASEJg?^ 


RECAP 


RD542  Mfl!i^^'*°^704i """        LAMMATION 


OF    THE 


VERMIFORM   APPENDIX: 


^     ITS 


EESULTS,  DIAGNOSIS,  AND  TEEATMENT, 

TOGETHER   WITH   THE 

REPORTS 

OF  SEVEN   CASES   OF  EXCISION   OF  THE  VERMIFORM    APPENDIX 

FOR  PERFORATIVE  APPENDICITIS,  WITH  EXHIBITION 

OF  FIVE  OF   THE   PATIENTS. 


BY 


THOMAS   G.   MORTON,  M.D., 

One  of  the  Surgeons  to  the  Pennsylvania  Hospital;  Surgeon  to  the  Philadelphia 
^       Orthopedic  Hospital ;  Professor  of  Orthopaedic  Surgery  at  the  Philadelphia 
Polyclinic  and  College  for  Graduates  in  Medicine,  etc.,  etc. 


Eead  before  the  College  of  Physicians  of  Philadelphia, 
January  1,  1890. 


PRINTED     BY 

J.   B.    LIPPINCOTT    COMPANY, 

PHILADELPHIA. 
1890. 


Rdsm 


ns± 


College  of  ^Jpsiicians;  anb  ^urseons; 


Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/inflamationofverOOmort 


IKFLAMMATIOlSr 


OF   THE 


VERMIFORM   APPENDIX: 


ITS 


EESULTS,  DIAGNOSIS,  AND  TEEATMENT, 


TOGETHER   "WITH    THE 


REPORTS 


OF  SEVEN  CASES  OF  EXCISION  OF  THE  VERMIFORM  APPENDIX 

FOR  PERFORATIVE  APPENDICITIS,  WITH  EXHIBITION 

OF  FIVE  OF  THE  PATIENTS. 


BY 

THOMAS   G.  MOETON,  M.D., 

One  of  the  Surgeons  to  the  Pennsylvania  Hospital ;  Surgeon  to  the  Philadelphia 

Orthopaedic  Hospital ;  Professor  of  Orthopgedic  Surgery  at  the  Philadelphia 

Polyclinic  and  College  for  Graduates  in  Medicine,  etc.,  etc. 


Read  before  the  College  of  Physicians  of  Philadelphia, 
January  1,  1890. 


PRINTED    BY 

J.   B.    LIPPINCOTT    COMPANY, 

PHILADELPHIA. 

18  90. 


INFLAMMATION 


OF    THE 


VERMIFORM  APPENDIX: 


ITS 


EESULTS,  DIAGNOSIS,  AND   TREATMENT* 


When  the  abdomen  is  believed  to  contain  pus, 
whether  intra-  or  extra-peritoneal,  encysted  or  dif- 
fused, the  rule  of  surgical  procedure  now  is  to 
make  a  section,  remove  the  offending  organ  or  the 
sloughing  tissues  or  pus,  thoroughly  cleanse  the 
surroundings,  and  drain. 

This  method  has  also  been  practised  in  the  treat- 
ment of  suppurative  peritonitis ;  in  perforating  ulcer 
of  the  intestine,  whether  typhoid,  tubercular,  trau- 
matic, or  simple  in  character ;  and,  more  recently,  in 
those  inflammations  and  abscesses  called  perityph- 
litic  or  pericsecal,  which  now  are  acknowledged  to 
be  almost  invariably  the  result  of  some  form  of  ap- 
pendicitis. It  is  to  the  latter  affection  that  I  wish 
to  call  attention  this  evening,  and,  in  doing  so,  to 
present  a  number  of  patients  from  whom  I  have 
removed  a  diseased  appendix  vermiformis,  which 

*  Read  before  the  College  of  Phj'-sicians  of  Philadelphia,  at  the 
stated  meeting  held  January  1,  1890. 

3 


iu  every  case  had  given  rise  to  peri-appendicular 
abscess  threatening  general  suppurative  peritonitis, 
which,  indeed,  in  several  had  already  begun. 

Laparotomy  for  perforative  appendicitis,  with  re- 
moval of  the  organ,  is  now  an  established  surgical 
procedure,  and  yet  so  recently  has  this  operation 
been  introduced  that  I  am  able  to  present  the 
patient  upon  whom  I  operated  in  April,  1887,  for 
pericgecal  abscess  with  peritonitis,  which  I  believe 
represents  the  first  successful  operation  for  the  re- 
moval of  the  vermiform  appendix  in  a  case  of  this 
kind,  based  upon  correct  diagnosis. 

It  is  true  that  Hall,  of  JS'ew  York,  in  1886,  in 
an  abscess  associated  with  right  inguinal  hernia, 
after  evacuating  the  abscess,  had  discovered  and 
removed  an  ulcerated  appendix,  and  the  patient 
recovered ;  but  the  diagnosis  of  perforative  appen- 
dicitis was  not  made  until  after  the  abscess  was 
opened.  More  recently,  a  number  of  cases  of 
excision  of  the  appendix  have  been  reported  by 
Weir,  Treves,  ITancrede,  and  others. 

In  the  case  to  which  I  have  referred  and  now 
present,  general  peritonitis  was  developing;  the 
history  and  symptoms  indicated  abscess,  and  pointed 
to  the  appendix  as  the  cause  of  trouble.  Upon 
incision,  an  abscess  cavity  was  entered  at  a  depth 
of  an  inch  or  more  below  the  external  surface,  a 
free  flow  of  pus  followed,  and  the  caecum  and  its 
diseased  appendix,  which  was  perforated,  came  into 
view.  The  latter  was  excised,  the  peritoneal  cavity 
washed  free  of  pus  and  drained,  with  immediate 
relief  and  prompt  recovery. 


I  have  operated  since  upon  six  other  cases.  Of 
these  seven,  five  recovered  and  two  died;  of  the 
latter,  both  were  unavoidably  operated  upon  in 
extremis,  and,  although  dying  within  a  few  hours, 
the  fatal  termination  was  in  no  wise,  I  think,  has- 
tened by  the  operation. 

Each  case  presented  a  distinct  history  of  a  num- 
ber of  previous  attacks  of  pain  in  the  ileo-csecal 
region,  which  occurred  generally  at  irregular  inter- 
vals, covering  periods  varying  from  a  few  months 
to  several  years. 

Four  were  males,  and  three  were  females ;  their 
ages  were  respectively  nine,  eleven,  seventeen, 
twenty-six,  twenty-eight,  thirty-four,  and  fifty-two 
years.  The  final  attack,  during  which  perforation 
took  place,  presented  symptoms  very  much  alike  in 
each :  intense  local  pain,  increased  on  pressure,  dis- 
tention of  the  ileo-csecal  region,  fluctuation  of  tem- 
perature, slight  rigors  or  marked  chills,  moderate 
or  decided  sweatings,  acceleration  of  pulse,  coated 
tongue,  constipation,  and  a  depressed,  anxious  facial 
expression. 

IvTo  tumor  could  be  detected  in  any  case,  but  in 
one  instance  there  was  some  deep  hardening  of  the 
tissues.  Percussion  in  this,  as  in  fact  in  the  other 
cases,  was  markedly  tympanitic. 

A  lateral  incision  was  made  in  each,  and  the 
peritoneal  cavity  was  found  invaded  by  pus  in  four 
of  the  cases.  In  all  more  or  less  intestine  came 
into  view,  either  as  part  of  the  limiting  abscess 
wall  or  penetrating  the  opening  through  it  to  the 
general  peritoneal  cavity.    The  appendix  was  found 


6 

attached  its  entire  length  to  the  caecum  in  three 
cases,  and  quite  free  in  the  other  four. 

Fecal  concretions  were  found  in  every  case  but 
one,  either  lodged  in  the  perforation  or  free  in  the 
abscess  or  peritoneal  cavity. 

The  abdominal  cavity  of  each  was  washed  out  and 
drained  from  the  lowest  part  of  the  pelvis.  The 
abscess  cavities  were  treated  by  irrigation  and 
partial  curetting.  The  wound  of  operation  was 
brought  together  by  interrupted  sutures  of  silk, 
but  in  each  case,  owing  to  increased  tension,  some 
of  the  sutures  had  to  be  cut  within  twenty-four 
hours,  and  healing  by  granulation  took  place. 
From  the  time  of  operation  the  symptoms  were 
invariably  promptly  relieved.  Convalescence  was 
uneventful  except  in  one  instance,  which  will  be 
referred  to  again. 

The  operations  were  performed  at  periods  vary- 
ing from  the  third  to  the  ninth  day  after  the  first 
symptoms  had  appeared. 

The  post-operative  treatment  consisted,  in  a  gen- 
eral way,  in  keeping  the  abdominal  cavity  drained 
and  the  bowels  acting  freely. 

Hypodermic  injection  of  morphine  was  reluct- 
antly used  upon  two  occasions,  shortly  after  the 
operation,  to  relieve  pain  and  restlessness. 

Milk  and  broths  were  freely  given,  while  stimu- 
lants and  quinine  were  early  required.  The  his- 
tories of  these  cases  are  briefly  as  follows  : 


CASE  I.— (Exhibited.)  APPENDICITIS  — PERFORATION  — PERI- 
TYPHLITIC  ABSCESS— GENERAL  PERITONITIS— LAPAROTOMY— 
EXCISION  OF  THE  VERMIFORM  APPENDIX— RECOVERY. 

This  patient  was  under  the  charge  of  Dr.  Frank 
"Woodbury,  with  whom  and  Dr.  James  C.  Wilson  I 
saw  the  case  in  consultation. 

Charles  M.  N.  K. ;  aged  twenty-six  years ;  born  in  Phila- 
delphia ;  a  paper-hanger ;  not  married ;  of  spare  frame ;  had 
always  had  good  health,  except  that  for  the  last  three  or 
four  years  he  had  been  subject  to  sudden  and  severe  attacks 
of  abdominal  pain.  These  attacks  came  on  without  warning 
while  he  was  in  excellent  health,  and  would  completely  pros- 
trate him.  The  pain  was  of  a  stabbing  character,  and  most 
intense  across  the  lower  part  of  the  abdomen  and  around 
the  umbilicus ;  it  was  attended  by  great  irritability  of  both 
rectum  and  bladder ;  sometimes  there  would  be  diarrhoea. 
These  attacks,  after  lasting  a  few  hours,  passed  away  gradually, 
leaving  him  rather  weak  for  a  short  time ;  but  he  rapidly  re- 
covered, and  enjoyed  uninterrupted  good  health  until  the  next 
attack  came  on.  He  consulted  Dr.  Woodbury  on  the  20th 
of  April,  1887,  complaining  of  having  taken  cold ;  looked 
haggard,  skin  and  conjunctivae  rather  sallow,  tongue  coated, 
no  appetite,  bowels  constipated,  frequent  micturition,  and  was 
passing  a  remarkably  large  quantity  of  pale  urine.  At  this 
time  he  did  not  complain  of  abdominal  pain.  He  was  given 
fractional  doses  of  calomel  and  sodium  bicarbonate  with 
pepsin,  and  was  directed  to  keep  his  room.  The  urine  con- 
tained a  large  proportion  of  albumen  (one-fifth  on  boiling), 
and  under  the  microscope  showed  many  leucocytes  and  a  few 
hyaline  casts. 

April  22. — Nauseated  during  the  night ;  bowels  moved  satis- 
factorily ;  great  irritability  of  the  bladder ;  much  prostration. 

April  23. — Spent  the  day  lying  upon  a  lounge ;  complained 
of  abdominal  pain ;  had  not  slept,  and  was  very  restless. 

April  24. — During  the  night  had  suffered  intensely  and  did 


8 

not  sleep  ;  several  copious  movements ;  pain  persisted ;  point  of 
greatest  tenderness  about  midway  between  the  umbilicus  and 
the  middle  of  Poupart's  ligament.  A  resisting  mass  could  be 
detected  upon  pressure  in  this  locality,  but  examination  caused 
severe  pain.     Temperature  103.5° ;  pulse  140. 

Ap7^il  25. — Had  a  very  bad  night ;  pain  in  right  iliac  region 
excruciating ;  swelling  somewhat  larger,  very  tender ;  skin  not 
discolored.  Dr.  James  C.  Wilson  saw  the  case  in  consulta- 
tion :  diagnosis,  either  intussusception  or  perityphlitic  abscess. 
Leeches  were  applied  over  the  spot  of  tenderness. 

April  27. — Symptoms  continue  about  the  same ;  general  con- 
dition poor ;  face  pale ;  features  pinched ;  beads  of  perspiration 
on  forehead.  I  was  called  and  advised  operation.  At  this  time 
his  condition  was  discouragingly  wretched,  that  of  a  man  in  the 
dying  stage  of  purulent  peritonitis.  At  2  p.m.  performed  lapar- 
otomy. The  field  of  operation  was  cleansed  with  soap  and  water, 
and  neighboring  hair  removed ;  the  surface  was  again  washed 
with  ether,  followed  by  corrosive  sublimate  solution  (1  to 
2000).  The  usual  antiseptic  precautions  were  observed  as  to 
instruments,  and  the  field  was  surrounded  by  towels  wet  with 
the  mercuric  solution.  The  incision  was  made  directly  over 
the  swelling,  and,  finding  the  deep  muscles  infiltrated  with  pus, 
it  was  extended  until  it  measured  nearly  ten  inches;  com- 
mencing just  above,  and  two  inches  to  the  right  of  the  umbil- 
icus, it  continued  obliquely  downward  nearly  to  the  pubes.  The 
peritoneum  was  opened  and  a  free  flow  of  pus  followed,  having 
a  decidedly  fecal  odor ;  general  purulent  peritonitis  present. 
In  the  abscess  cavity,  near  the  appendix,  was  found  a  fecal 
concretion  about  the  size  of  a  cherry-stone.  The  vermiform 
appendix  was  greatly  swollen,  and  exhibited  a  perforating 
ulcer  extending  three-fourths  around  its  circumference,  and 
very  near  to  the  point  of  origin.  A  silk  ligature  was  applied 
close  to  the  caecum  and  at  the  terminal  portion  of  the  appen- 
dix, and  the  intervening  portion,  comprising  almost  the  whole 
organ,  was  removed,  together  with  a  large  portion  of  omentum 
which  projected  into  the  abscess  cavity,  the  walls  of  which 
were  then  scraped  with  a  curette  and  douched  with  simple 
hot  (110°)  water.    The  peritoneal  cavity  was  likewise  douched 


9 

until  free  of  pus,  and  a  drainage-tube  was  carried  into  the 
lowest  part  of  the  pelvic  basin. 

Following  the  operation,  he  entered  upon  convalescence, 
which  was  uninterrupted.  He  was  free  from  all  pain  ;  the 
bowels  moved  naturally.  The  temperature  fell  after  the  opera- 
tion, and  did  not  again  rise  above  100°.  The  drainage-tube 
was  removed  piecemeal,  the  last  portion  being  taken  away  on 
the  fifteenth  day.  Went  out  May  21st.  His  recovery  was  as- 
sured by  careful  nursing,  and  by  the  administration  of  milk 
and  small  quantities  of  prepared  liquid  foods. 


CASE  II.— APPENDICITIS  — PERFORATION  — PERITYPHLITIC  AB- 
SCESS—GENERAL PERITONITIS— ABDOMINAL  SECTION— EXCI- 
SION OF  APPENDIX— DEATH. 


This  case  I  saw  in  consultation  with  Dr.  Ed.  G. 
Stone,  of  Philadelphia,  and  operated  upon  it  for 
him. 

Mrs.  G. ;  set.  thirty-four ;  mother  of  one  child  ;  had  been  per- 
fectly healthy  up  to  time  of  last  illness,  save  for  occasional 
attacks  of  colic,  which  had  readily  yielded  to  anodynes.  It  was 
said  that  she  had  had  a  severe  attack  of  pain  and  vomiting 
some  months  before.  For  two  days  previous  to  February  18, 
1887,  she  severely  exerted  herself  while  the  menses  were  over- 
due. On  that  day  she  had  severe  abdominal  pain  accompanied 
by  vomiting.  The  pain  was  described  as  starting  in  the  right 
hypochondriac  region  and  darting  to  the  umbilicus.  No  tumor 
was  perceptible,  neither  was  there  tenderness  upon  pressure. 
Anodynes  and  counter-irritation  were  ordered.  February 
19,  pain  less;  no  emesis  nor  rise  of  temperature;  some  sore- 
ness and  tenderness  to  the  right  of  the  umbilicus.  Pain  re- 
turns as  anodyne  effects  pass  off.  Bowels  have  not  moved  for 
several  days.  Abdomen  somewhat  tympanitic,  tongue  coated 
and  dry  at  tip.  Evening  temperature,  100° ;  pulse  90.  Treat- 
ment continued. 

February  20. — Eestless  night.   Vomits  yellow  material  freely. 


10 

Abdomen  tympanitic  and  tender.  Temperature  101°  ;  pulse 
110.     Operation  urged  but  refused. 

February  21, — Symptoms  continue.  She  is  more  quiet  but 
weaker.  Abdomen  very  large  and  tender.  On  the  morning 
of  this  day  I  first  saw  the  case,  and,  although  her  condition 
was  very  unfavorable,  urged  abdominal  section  as  her  only 
chance  for  life.  My  diagnosis  was  perforated  appendix  and 
subsequent  peritonitis. 

Free  incision  was  made  laterally  over  the  csecal  region,  and 
the  appendix  found  greatly  enlarged  and  perforated  in  two 
places,  each  hole  measuring  a  little  more  than  one-fourth  inch  in 
diameter.  A  silk  ligature  was  placed  upon  the  appendix  close 
to  the  caecum,  and  the  ofiending  organ  then  removed.  There 
was  also  present  difiuse  purulent  peritonitis.  The  abdominal 
cavity  was  thoroughly  irrigated,  the  region  of  abscess  cleansed, 
and  a  drain  inserted.     She  died  in  a  few  hours. 


CASE  III.— APPENDICITIS— PERFORATION— PERITYPHLITIC  AB- 
SCESS-GENERAL PERITONITIS— ABDOMINAL  SECTION— EXCI- 
SION OF  APPENDIX— DEATH. 

On  the  13th  of  January,  1888, 1  was  called  in  consultation 
with  Dr.  B.  Trautmann,  of  this  city,  to  a  child  nine  years  of 
age.  It  seemed  that  she  had  suffered  from  headache,  and  fre- 
quent attacks  of  pain  in  the  abdomen.  She  attended  school 
until  just  before  Christmas,  when  she  had  a  severe  colicky 
attack,  but  subsequent  to  this  was  apparently  quite  well,  and 
on  December  31  was  out  with  her  sled  for  several  hours.  On 
January  6  she  was  seized  with  nausea,  abdominal  pains,  and 
developed  high  fever.  After  this  she  was  so  much  better  that 
she  was  down  stairs,  and  ate  of  sausage  and  rolls.  Soon  after 
she  was  seized  with  violent  abdominal  cramps,  the  right  iliac 
region  being  exceedingly  painful.  Upon  January  12  she  had 
an  attack  of  pain  which  was  most  excruciating  in  character. 
The  following  day,  when  I  first  saw  her,  the  condition  was 
wretched,  almost  that  of  collapse,  but  not  to  such  an  extent 
as  to  justify  denial  of  her  only  chance  of  life,  as  I  had  diag- 
nosticated peritonitis  originating  in  a  perforated  appendix 


11 

and  advised  operation.  Upon  making  lateral  abdominal  in- 
cision, as  soon  as  the  peritoneum  was  opened  a  great  flow  of 
putrid  pus  took  place,  then  the  caecum  and  appendix  came 
into  view ;  the  latter  was  greatly  swollen,  and  both  it  and  the 
caecum  were  covered  with  greenish-yellow  pyogenic  membrane 
and  lymph.  The  appendix  was  gangrenous  for  some  distance, 
and  its  end  had  sloughed  off.  One  foreign  body  was  found  in 
the  abscess  cavity,  another  was  partly  held  in  the  sloughing 
end  of  the  organ,  while  two  other  concretions  were  in  the 
canal  near  the  caecum.  The  appendix  was  ligatured  at  its  base 
and  exsected.  The  whole  abdominal  cavity  and  its  intestinal 
contents,  which  were  in  a  state  of  purulent  inflammation, 
were  then  thoroughly  inundated  with  hot  water ;  a  glass  tube 
was  carried  into  the  pelvis,  and  the  wound  was  closed  and 
dressed  in  the  usual  manner.  The  child  never  reacted  fully, 
but  died  seven  hours  afterwards. 


CASE  IV.— (Exhibited.)  APPENDICITIS  — PERITYPHLITIC  AB- 
SCESS—INCISION AND  DRAINAGE  (1886)— RECURRENCE  OF  AP- 
PENDICITIS —  PERFORATION  —  PERITYPHLITIC  ABSCESS— AB- 
DOMINAL SECTION— EXCISION  OF  APPENDIX— RECOVERY  (1888). 

L.  A.  B.,  a  stout  girl,  of  healthy  parentage,  and  with  no 
family  history  of  caecal  or  appendicular  disease,  had  a  severe 
fall  upon  the  buttocks  in  March,  1884.  She  was  almost  im- 
mediately seized  with  a  terrible  attack  of  vomiting  and  retch- 
ing, which  lasted  hours.  From  this  time  until  September, 
1885,  she  suffered  with  extremely  painful  menstrual  epochs, 
and  from  time  to  time,  when  tired,  had  a  recurrence  of  vomit- 
ing similar  to  that  immediately  succeeding  her  fall.  On  Sep- 
tember 10,  during  the  progress  of  one  of  these  vomiting  spells, 
she  experienced  severe  pains  in  the  right  caecal  region,  the 
whole  seizure  lasting  about  ten  days.  Another  attack  devel- 
oped on  September  29,  and  still  others  on  November  10  and 
23.  The  latter  was  brought  on  by  taking  cold,  and  in  five 
hours  she  was  compelled  to  go  to  bed,  and  endured  the  most 
excruciating  drawing  pain,  which  radiated  from  the  right 
caecal  region  to  the  shoulder-blade  of  the  same  side.  Vomit- 
ing continued  for  some  hours,     Emesis  then  ceased,  but  the 


12 

pains  continued  off  and  on  until  January  10,  1886,  when  I 
first  saw  the  patient.  A  hardening  was  then  present  in  the 
right  ileo-csecal  region.  Poultices  and  mercurial  inunctions 
were  ordered,  which  gave  very  marked  relief.  She  daily 
seemed  to  improve,  and  before  March  19  had  resumed  her 
household  duties.  On  that  date  she  was  much  overworked 
in  caring  for  company,  and  about  midnight  was  seized  with 
torturing  pains  in  the  region  of  the  hardening.  These  con- 
tinued until  April  3,  1886,  when  I  incised  the  now  greatly 
enlarged  mass,  liberated  a  large  quantity  of  fetid  pus,  and 
introduced  a  drainage-tube.  There  was  apparently  no  commu- 
nication with  the  caecum  or  its  appendix.  The  tube  remained 
for  a  long  time,  and  the  wound  did  not  completely  close  until 
August.  Her  condition,  however,  had  meanwhile  improved 
amazingly,  and  she  was  soon  quite  herself  again,  being  up 
and  about  the  house  in  four  weeks. 

After  this,  especially  when  tired  out  or  at  a  menstrual 
period,  the  patient  suffered  with  pain  localized  about  the 
csecal  region.  The  attacks  resembled  colic.  Three  months 
after  operation  she  had  quite  a  severe  attack  of  local  pain 
which  lasted  a  number  of  hours.  These  attacks,  at  long  in- 
tervals, presented  about  the  same  characteristics.  The  last 
occurred  in  January,  1888,  which  was  accompanied  by  more 
severe  pain  than  any  of  the  others. 

During  the  evening  of  Friday,  March  15,  of  the  same  year, 
she  was  taken  with  violent  vomiting  and  purging.  These 
symptoms  continued  all  night,  and  through  Saturday,  when 
the  pain  was  most  intense.  On  Sunday  her  symptoms  ap- 
peared grave.  Pain  was  increased  on  pressure  in  the  right 
ileo-csecal  region.  Abdomen  soft;  fever;  rapid  pulse  and 
dry  tongue.  On  Monday  the  symptoms  continued  the  same, 
with  a  temperature  of  102°.  In  the  afternoon  the  general 
symptoms  were  more  serious.  No  tumor  could  be  felt,  pain 
increased.  Skin  was  bathed  with  sweat.  There  was  marked 
resonance  over  the  part.  On  Tuesday  the  pulse  was  feeble, 
nausea  and  occasional  sick  stomach  prevailed.  The  other 
symptoms  remained  about  the  same ;  diagnosis  of  perforated 
appendix  with  abscess  was  then  made.     The  same  morning 


13 

she  was  etherized  and  the  usual  lateral  incision,  five  inches 
long,  was  made.  This  came  about  an  inch  further  externally 
than  the  line  of  incision  of  the  first  operation.  The  deep 
tissues  of  the  abdominal  wall  were  somewhat  oedematous, 
and  just  before  the  peritoneum  was  reached  a  large  quantity 
of  most  fetid  pus  was  liberated.  At  the  base  of  this  cavity 
the  caecum  and  appendix  were  clearly  visible.  The  latter  was 
enormously  enlarged  and  thickly  covered  with  lymph  and 
abscess-lining  membrane.  A  large  opening  in  the  abscess 
wall  communicated  with  the  cavity  of  the  general  peritoneum. 
Through  this  small  intestines  were  forced  when  she  coughed. 

The  appendix  was  firmly  attached  to  the  caecum,  from 
which  it  was  separated  with  some  difficulty.  It  was  then 
firmly  ligatured  with  a  stout  silk  at  its  junction  with  the  caecum 
and  excised.  The  communication  with  the  general  perito- 
neum was  then  enlarged  by  tearing,  and  through  it  the  intes- 
tines were  most  thoroughly  washed  by  means  of  hot  water 
irrigations.  The  abscess  cavity  proper  and  surrounding  parts 
were  sponged  with  one  to  one  thousand  mercuric  solution.  A 
glass  drainage-tube  was  then  carried  to  the  bottom  of  the  pelvis 
and  brought  out  through  the  lower  angle  of  the  wound,  while 
a  larger  rubber  tube  drained  the  abscess  cavity  proper  and 
emerged  at  the  upper  extremity  of  the  wound. 

The  incision  was  then  closed  and  an  antiseptic  dressing 
applied.  She  reacted  well.  On  the  following  day  immense 
swelling  necessitated  cutting  of  all  the  stitches,  whereupon 
the  caecum  lay  in  full  view  at  the  bottom  of  the  wound,  but 
no  prolapse  of  intestine  at  any  time  took  place. 

Great  sloughs  kept  coming  away  for  many  days,  also  much 
pus,  in  spite  of  every  eflbrt  to  keep  the  wound  aseptic.  The 
deep  glass  or  pelvic  drain  became  dry  on  the  fourth  day  and 
was  removed  on  the  fifth.  From  that  time  the  wound  was 
kept  lightly  packed  with  antiseptic  material  and  rapidly  gran- 
ulated to  the  surface,  when  a  few  strips  of  rubber  plaster  were 
applied  and  cicatrization  became  complete. 

Patient's  bowels,  from  time  of  operation,  were  kept  in  a 
freely  moving  condition  by  means  of  citrate  of  magnesia  and 
enemata.     In  less  than  a  month  the  patient  was  well,  and  has 


14 

since  married.  The  appendix  was  found  to  be  the  seat  of  a 
very  large  perforating  ulcer,  situated  near  its  caecal  attach- 
ment, but  no  foreign  body  was  discovered. 

Eighteen  months  after  operation,  as  result  of  immense 
obesity  and  continued  bronchial  cough,  a  hernia  of  consider- 
able dimensions  appeared  beneath  the  double  cicatrix.  This, 
however,  has  not  increased  in  size;  is  easily  kept  reduced  by  a 
truss,  and  gives  the  patient  scarcely  any  annoyance. 


CASE  v.— (ExMbited.)  APPENDICITIS  —  PERITYPHLITIC  AB- 
SCESS—PERFORATION— LAPAROTOMY— EXCISION  OF  THE  AP- 
PENDIX—GANGRENE OF  THE  C^CUM— FECAL  FISTULA— RE- 
COVERY. 

Seen  in  consultation  with  Drs.  Eich  and  Sailor, 
of  Williamsport,  Penna. 

J.  W.  C,  seventeen  years  of  age,  usual  weight  one  hundred  and 
eighty  pounds,  had  a  severe  attack  of  ileo-caecal  pain  some  time 
in  November,  1887,  while  at  school,  which  laid  him  up  for  three 
days,  and  in  the  following  spring  he  had  a  similar  but  less  severe 
attack.  On  July  4,  1888,  he  indulged  in  an  enormous  amount 
of  peanuts  and  cherries,  but  felt  no  special  inconvenience,  save 
constipation,  until  three  days  subsequently,  when  he  experi- 
enced colicky  pains  and  had  a  somewhat  watery  stool.  For 
two  days  there  was  some  looseness  of  the  bowels  associated  with 
severe  cramps.  At  this  time  there  developed  great  tenderness 
in  the  right  iliac  region  and  he  could  not  stand  erect.  On 
July  11,  a  telegram  from  Williamsport,  Pa.,  reached  me  at 
Newport,  E.  I.,  but  I  was  not  able  to  reach  the  patient  until 
the  13th,  when  I  found  him  in  a  most  serious  condition.  Al- 
though he  had  symptoms  of  obstruction,  yet  the  diagnosis  of 
perforation  of  the  appendix,  abscess,  and  peritonitis  was  in- 
stantly made.  The  pain,  violent  variations  of  temperature, 
profuse  sweating,  and  profound  exhaustion  indicated  pus, 
while  the  previous  history  of  attack  of  colic  and  pain  in  the 
ileo-csecal  region,  all  pointed  to  the  appendix  as  the  source 
of  trouble. 

I  promptly  made  a  lateral  abdominal  section,  evacuated  an 


15 


abscess  of  considerable  size,  and  soon  came  upon  a  perforated 
appendix,  which  was  closely  attached  to  the  caecum  its  entire 
length.  The  end  of  the  appendix  had  sloughed  off,  and  in 
this  disorganized  tissue  I  found  a  large  oval  fecal  concretion, 
which  evidently  had  been  the  cause  of  the  disturbance.  Two 
very  large  portions  of  omentum  were  so  constricted  by  lymph- 
bands  that  gangrene  had  occurred,  and  there  was  general 
peritonitis.  The  appendix  was  tied  and  cut  off  close  to  its 
csecal  attachment ;  two  large  portions  of  the  gangrenous  omen- 
tum were  removed,  and  the  abscess  cavity  cleansed,  as  were 
likewise  the  entire  abdominal  contents.  The  csecum  had  very 
much  the  shape  and  feel  of  a  sausage,  was  firm  and  dark  in 
color,  and  bound  down  as  the  result  of  inflammation.  Thor- 
ough drainage  of  the  abdominal  cavity  was  secured  by  a  glass 
drainage-tube  passing  to  the  bottom  of  the  pelvic  cavity, 
while  a  rubber  tube  drained  the  abscess  proper. 

No  attempt  was  made  to  approximate  the  wound,  but  its 
cavity  was  lightly  packed  with  antiseptic  gauze,  with  the 
usual  dressing  upon  the  abdomen. 

The  patient  did  fairly  well  after  the  operation  ;  took  food 
well,  but  there  was  no  action  of  the  bowels.  Two  days  later 
he  had  marked  rise  of  temperature  and  great  restlessness ; 
passing  water  frequently,  and  had  almost  constant  desire  to 
evacuate  the  bowels,  but  without  succeeding  in  doing  so.  In 
response  to  a  telegram  stating  that  the  patient  was  desperately 
ill,  my  son.  Dr.  T.  S.  K.  Morton,  went  to  Williamsport,  and 
upon  examination  discovered  an  impaction  of  faeces  in  the 
large  bowel  which  extended  from  caecum  to  anus.  After  some 
twelve  hours'  work  with  the  rectal  tube  and  half-hourly  doses 
of  calomel  and  podophylliu,  the  colon  was  cleared  of  several 
pounds  of  fecal  matter,  and  the  patient's  condition  immedi- 
ately became  much  improved,  and  continued  to  do  so  steadily 
until  convalescence  took  place.  At  the  time  of  the  impaction 
it  was  discovered  that  fecal  matter  was  passing  into  the  ab- 
dominal wound,  and  examination  showed  that  the  caecum  had 
given  way,  for  two  gangrenous  spots  were  found,  each  about 
half  an  inch  in  diameter,  on  the  uppermost  part  of  the  ex- 
posed bowel.    These  soon  coalesced  into  one  opening.     Sub- 


16 

sequently  the  patient  rapidly  improved  and  regained  his  usual 
rugged  health.  The  wound  of  operation  and  fecal  fistula 
closed  naturally  in  five  months. 


CASE  VI.  — (Exhibited.)  APPENDICITIS  —  PERITYPHLITIC  AB- 
SCESS —  PERFORATION  —  LAPAROTOMY  —  EXCISION  OF  THE 
A  PPENDI X— RECOVERY. 

H.  A.  R.,  aged  fifty-two ;  has  always  had  good  health,  with 
the  exception  of  a  mild  attack  of  bronchitis  several  years  ago, 
which  did  not  confine  him  to  bed.  Four  months  ago  he  had 
the  first  attack  of  pain  in  the  right  ileo-caecal  region ;  this 
had  since  recurred  several  times.  The  pains  generally 
awakened  him  at  night,  but  usually  were  soon  relieved  by 
stimulants.  Pressure  over  the  csecal  region  always  increased 
his  sufiering.  On  September  4  he  called  upon  Dr.  Bernard 
Bereus,  of  this  city,  and  complained  of  being  stifi"  and  sore 
all  over,  particularly  in  thighs  and  abdomen.  His  tongue 
was  furred,  pulse  72,  skin  moist.  Was  ordered  calomel  and 
opium.  On  the  6th  he  called  again,  with  more  abdominal 
pain  which  was  diffuse,  but  this  time  not  increased  by  pressure. 
Some  difficulty  in  walking  and  some  anorexia  were  present, 
but  not  enough  to  prevent  him  from  attending  to  business. 
On  the  7th  he  again  saw  Dr.  Bereus,  when  his  condition  was 
found  to  be  more  serious.  He  had  great  pain  in  the  abdomen, 
and  now  had  tenderness  on  pressure  ;  pulse  72 ;  skin  dry ;  was 
obliged  to  leave  his  business  office  at  noon,  and  took  to  bed. 
At  8.30  that  evening  he  had  rigors,  but  not  a  full  chill ;  pulse 
98,  temperature  102f  °,  skin  hot,  tongue  dry,  abdomen  distended, 
tympanitic,  and  tender  to  touch  over  its  entire  surface.  On 
the  8th,  had  passed  a  good  night  with  morphine ;  bowels  were 
freely  moved  by  sulphate  of  magnesia ;  condition  of  abdomen 
unchanged  ;  morning  temperature  100|° ;  evening  temperature 
103°.  The  next  day,  September  9,  condition  about  the  same 
except  increased  pain  over  the  appendix  region.  On  the  10th, 
the  morning  temperature  was  101° ;  pulse  92 ;  facial  appearance 
dusky  ;  pain  especially  severe  in  right  iliac  region  with  well- 
defined  fulness,  and  intense  pain  on  pressure  at  that  point. 


17 

From  the  intense  pain,  more  especially  over  the  appendix, 
the  slight  sweat,  the  fluctuating  temperature,  the  anxious 
facial  expression,  depressed  appearance  and  gradual  increase 
of  symptoms,  the  diagnosis  of  typhlitic  abscess  and  peritonitis 
was  made.  At  12.30,  the  same  day,  I  saw  the  patient,  con- 
firmed the  diagnosis,  and  at  once  made  preparations  for 
evacuating  the  abscess  and  excising  the  appendix,  which 
was  believed  to  be  the  subject  of  perforation.  At  4.30  p.m., 
the  usual  lateral  incision  was  made,  six  inches  in  length,  di- 
rectly over  the  site  of  the  appendix.  The  abdominal  walls 
were  very  thick,  and  it  was  not  until  the  caecum  was  reached 
that  pus  was  found.  This  was  exceedingly  offensive  and  in 
considerable  amount.  It  had  worked  its  way  into  the  right 
side  of  the  pelvis.  With  some  diflBculty  the  under  surface 
of  the  csecum  was  brought  into  view  and  two  very  similar 
masses  of  tissue,  either  one  of  which  might,  from  its  appear- 
ance, have  been  taken  for  the  appendix,  were  found  lying  near 
each  other  and  quite  firmly  attached  to  the  under  part  of  the 
csecum.  These  masses  seemed  made  up  of  fat  and  cellular 
tissue,  and  were  about  two  inches  long,  judging  from  the 
position  of  the  one  nearest  the  caput  coli,  and  the  position 
the  appendix  should  occupy,  this  one  was  carefully  separated 
from  the  intestine,  and  a  ligature  placed  upon  it  as  near  its 
csecal  attachment  as  possible,  and  it  was  then  cut  ofi*.  It 
proved  to  be  the  appendix  embedded  in  lymph.  A  ragged 
perforation  was  found  in  it  about  one-fourth  of  an  inch  from 
its  distal  end.  The  second  intestinal  appendage  proved  to  be 
an  hypertrophied  epiploic  body.  There  was  considerable 
recent  lymph  surrounding  the  appendix  and  colon.  The  ex- 
posed parts  were  carefully  curetted  and  douched.  During  the 
search  for  the  appendix,  and  subsequently  in  the  course  of  the 
operation,  intestines  protruded  considerably.  The  abdominal 
cavity  was  very  thoroughly  washed  out ;  and,  subsequently, 
a  glass  drainage-tube  was  placed  at  the  bottom  of  the  pelvis, 
a  large  rubber  drain  was  also  placed  up  along  the  ascending 
colon.  With  some  difficulty  the  intestines  were  returned, 
and  the  wound  was  finally  brought  together  with  silk  thread. 
The  temperature,  three  hours  after  the  operation,  was  101 1°, 

2 


18 

but  gradually  lessened,  never  reached  101°  again,  and  on  the 
tenth  day  was  normal. 

Three  hypodermic  injections  of  one-sixth  of  a  grain  of  mor- 
phine were  administered  to  relieve  pain,  two  at  intervals  of 
five  hours  after  the  operation,  and  the  last  one  eight  hours 
subsequently.  Calomel  in  doses  of  one-sixth  of  a  grain  was 
given  every  hour  after  operation  until  the  bowels  moved  very 
freely.  Milk,  coffee,  and  champagne,  in  small  and  frequently 
repeated  doses,  were  given  from  the  first,  also  twelve  grains 
of  quinine  daily. 

Great  tension  of  the  wound  necessitated  cutting  away  the 
sutures  on  the  second  and  third  days,  after  which  large  sloughs 
kept  coming  away  for  ten  days.  Healing  by  granulation  took 
place.  Glass  drain  worked  out  on  twelfth  day ;  the  rubber 
one  on  the  fifth  day. 

The  wound  was  dressed  and  fresh  cotton  placed  in  the  glass 
drain  every  four  hours  for  the  first  five  days,  and  gradually 
the  dressings  were  changed  morning  and  evening  only,  until 
final  cicatrization  occurred. 

Convalescence  was  uneventful  and  rapid. 

CASE  VII.— (Exhibited.)  PERFORATIVE  APPENDICITIS— AB- 
SCESS—LAPAROTOMY— EXCISION  OF  THE  APPENDIX— RECOV- 
ERY. 

On  November  5,  1889,  I  saw  in  consultation  with  Dr. 
C.  H.  Shivers,  of  Haddonfield,  New  Jersey,  and  Dr.  J.  T. 
Hampton,  of  this  city,  Lemuel  O.,  a  lad  of  eleven  years 
of  age,  who,  a  few  days  before,  when  playing  in  the  garden, 
had  been  accidentally  struck  in  the  right  iliac  region  by 
the  handle  of  a  spade.  Intense  pain  followed ;  but  the  boy 
was  not  wholly  confined  to  his  bed  until  the  day  subse- 
quent to  the  injury ;  on  the  fifth  day  there  was  a  tempera- 
ture of  101|°,  pulse  120,  respiration  44,  dry  tongue.  Eight 
iliac  region  was  very  tense,  swollen,  and  exceedingly  painful 
to  the  merest  touch ;  there  was  no  pain  in  any  other  part  of 
the  abdomen,  no  localized  tumor,  and  not  the  least  dulness 
on  percussion;  the  bowels  had  been  kept  open  by  salines. 
The  boy  had  two  days  before  a  slight  but  positive  rigor,  which 


19 

was  followed  by  decided  perspiration  ;  careful  inquiry  brought 
out  the  fact  that,  on  very  many  occasions  during  the  previous 
two  or  three  years,  he  had  had  sudden  attacks  of  colic,  which 
had  been  ascribed  to  "internal  hernia."  The  pain  had  al- 
ways been  located  in  the  appendix  region.  During  the  inter- 
vals of  the  attacks  he  had  been  quite  well.  With  this  history, 
I  felt  convinced  that  there  had  been  chronic  appendicitis,  with 
probably  a  foreign  body  in  the  organ,  and  that  the  injury 
produced  by  the  blow  of  the  spade-handle  had  lighted  up  an 
attack  of  acute  inflammation  in  the  already  diseased  appen- 
dix, which,  becoming  ulcerated,  had  ended  in  perforation  ;  and 
although  all  the  symptoms  of  abscess  were  not  present,  yet 
that  unqestionably  pus  had  formed,  and,  since  the  patient  had 
progressively  grown  worse,  danger  of  extension  of  inflamma- 
tion or  of  the  abscess  opening  into  the  peritoneal  cavity  was 
very  great.  Hence  I  was  able  to  confirm  Dr.  Shivers's  able 
diagnosis,  and  to  urge — as  he  had  already  done  and  for  which 
I  had  been  summoned — an  immediate  operation.  Lateral 
abdominal  section  was  performed  on  November  6.  The 
incision  began  an  inch  above  the  middle  of  Poupart's  liga- 
ment, and  was  continued  upward  and  outward  four  inches ; 
on  reaching  the  colon  (the  tissues  were  all  normal  so  far)  and 
turning  it  up  in  search  of  the  appendix,  an  abscess  was  found 
which  contained  an  ounce  and  a  half  or  two  ounces  of  very 
fetid  pus.  The  appendix  was  found  glued  to  the  caecum  ;  it 
was  enlarged,  thickened,  covered  with  lymph,  and  presented 
a  perforation  about  a  quarter  of  an  inch  from  the  extremity. 
In  the  perforation  was  found  a  small  fecal  concretion.  A 
silk  ligature  was  placed  on  the  appendix  close  to  its  root,  and 
the  distal  extremity  was  excised.  The  peritoneal  cavity  was 
then  flooded  with  large  quantities  of  recently-boiled  water ; 
a  large  glass  drain  was  carried  through  the  coils  of  the  intes- 
tine to  the  bottom  of  the  pelvis,  and  a  rubber  drain  was  placed 
in  the  abscess  cavity  alongside  of  the  colon  ;  then  the  wound 
was  brought  together  with  silk  sutures,  and  a  dressing,  held 
in  place  by  a  four-tailed  binder,  was  applied.  Milk  was  given 
at  short  intervals,  and  the  bowels  were  kept  freely  open  by 
calomel  and  salines.    Convalescence  was  uninterrupted.    The 


20 

day  following  the  operation  there  was  great  tension  of  the 
wound,  and  all  the  sutures  were  cut,  leaving  the  wound  gap- 
ing open.  Peroxide  of  hydrogen  worked  like  a  charm  in 
keejDing  the  wound  and  drain  sweet  and  clean  and  in  assisting 
slough  separation. 

The  rubber  drain  was  taken  out  on  the  third  day,  and  the 
glass  drain  worked  out  on  the  ninth  day.  The  wound  was 
closed  on  the  twenty-eighth  day,  and  the  boy  was  about  the 
house  during  the  fifth  week. 

In  presenting  the  foregoing  cases,  I  feel  war- 
ranted in  making  a  few  practical  observations 
upon  the  operation  of  removal  of  a  diseased  appen- 
dix ;  its  relations  to  typhlitis  and  peritonitis ;  and 
especially  upon  the  time  and  indications  for  opera- 
tion, with  the  details  of  treatment  before  and  after 
operation.  One  thought  naturally  presents :  it  is, 
that  only  a  short  while  ago,  under  the  ideas  then 
prevailing  with  regard  to  the  treatment  of  such 
cases,  each  of  the  patients  here  presented  either 
would  have  perished,  or  would  be  living  in  constant 
fear  of  the  repetition  of  an  attack  which  might  at 
any  time  prove  fatal.  If  we  review  the  progress  of 
this  operation  of  exposing  the  diseased  appendix 
and  excising  it,  thus  removing  the  cause  of  repeated 
attacks  in  simple  or  in  perforative  appendicitis,  it 
is  interesting  to  note  the  gradual  development  of 
the  procedure. 

Mr.  Hancock,  of  London,*  in  1848,  appears  to 
have  been  the  first  to  urge  operative  interference 
in  perityphlitic  abscess  by  free  incision  and  drain- 
age, but  this  did  not  meet  with  much  favor  until  it 


*  London  Medical  Gazette,  1848,  p.  547. 


21 

received  the  endorsement  and  able  advocacy  of 
Willard  Parker,*  in  186,7. 

In  1878,  Sands,  of  New  York,  v^as  able  to  report 
twenty  cases  treated  in  this  way,  and  in  1883, 
William  Pepper,  at  a  meeting  of  the  Pennsylvania 
State  Medical  Society,  presented  the  statistics  of 
one  hundred  cases  contributed  by  l^oyes,  of  Rhode 
Island.  From  these,  and  numerous  other  con- 
tributions to  the  literature  of  the  subject,  it  was 
fully  and  finally  demonstrated  that  surgical  inter- 
ference in  cases  of  so-called  perityphlitic  abscess 
largely  reduced  the  mortality  of  this  afi*ection. 
This  was  a  decided  step  in  advance  upon  the  old 
method  of  non-interference,  which,  strange  though 
it  may  appear,  is  still  advocated  in  some  medical 
text-books.  Surgical  writers,  on  the  contrary,  now 
generally  urge  early  operation,  which,  as  has  been 
shown,  does  not  increase  the  risk  to  the  patient, 
but  places  him  in  a  position  greatly  more  favora- 
ble to  recovery. 

After  the  remarkably  successful  abdominal  sur- 
gery of  Tait,  Keith,  and  others  had  shown  that 
the  peritoneal  cavity  might  be  opened  and  ex- 
plored with  comparative  impunity,  it  was  but 
natural  that  surgeons  should  be  led  to  apply  the 
same  rules  to  the  treatment  of  perityphlitic  ab- 
scess, and  open  it  more  freely  than  before;  then 
to  explore  its  cavity,  examine  the  vermiform  ap- 
pendix, and  to  amputate  this  unnecessary  and 
dangerous  organ  when  the  subject  of  appendicitis 

*  Medical  Kecord,  New  York,  1887. 


22 

or  ulceration,  whether  perforating  or  not.  This 
has  been  the  final  step  in  the  operative  treatment 
of  perityphlitis. 

To  the  diagnosis,  indications  for  operation,  and 
details  of  treatment  before,  during,  and  after  sur- 
gical interference,  I  shall  now  direct  attention. 

Diagnosis. — One  of  the  earliest  and  most  constant 
symptoms  of  acute  appendicitis  is  pain,  which  may 
be  slight  or  stabbing  in  character,  and  usually  is 
increased  very  much  by  pressure.  It  comes  on  in 
attacks  or  paroxysms  (which  may  be  years  or  months 
apart),  during  which  there  may  be  nausea  and  even 
vomiting,  but  not  necessarily.  The  temperature  is 
slightly  elevated ;  constipation  is  commonly  present; 
the  pulse  is  generally  accelerated;  the  ileo-csecal 
region  may  be  tympanitic,  or  it  may  be  more  or 
less  dull.  These  symptoms  sooner  or  later  may 
disappear,  and  convalescence  be  established,  but  a 
relapse  or  recurrence  would  indicate  that  a  source 
or  irritation  continues.  After  a  variable  period 
the  attack  is  renewed,  and  perhaps  with  graver 
symptoms,  or,  during  an  apparently  mild  attack, 
the  sudden  advent  of  violent,  local,  and  constitu- 
tional symptoms  announces  very  positively  the  oc- 
currence of  inflammation  of  the  appendix,  with 
pus-formation,  or  peritonitis. 

The  fact  of  occurrence  of  an  attack  of  appendi- 
citis, although  apparently  entirely  recovered  from, 
is  serious  enough  to  give  rise  to  apprehensions  for 
the  future;  for  the  patient  is  liable  at  any  time, 
from  a  blow,  fall,  undue  exercise,  straining,  indi- 
gestion, or  even  without  apparent  cause,  to  have  a 


23 

recurrence  of  irritation  in  the  appendix,  which 
may  terminate  in  inflammation,  ulceration,  and 
perforation.  The  number  of  attacks  or  relapses 
or  recurrences  before  ulceration  takes  place  varies, 
but  when  several  have  occurred  it  is  almost  cer- 
tain that  the  appendix  is  seriously  diseased.  After 
one  or  more  attacks  the  patient  may  remain  ap- 
parently well,  but  as  a  rule  this  is  not  the  case,  and 
attack  upon  attack  at  gradually  shortening  inter- 
vals very  conclusively  demonstrate  that  the  appen- 
dix is  the  source  of  the  trouble,  and  that  perfora- 
tion, if  not  actually  present,  is  liable  to  occur  at  any 
time.  The  subject  of  such  an  attack  may  occasion- 
ally recover  without  surgical  interference,  through 
atrophy  of  the  organ  or  adhesion  to  the  caecum  with 
more  or  less  complete  obliteration  of  its  calibre. 
But  such  a  favorable  result  must  be  the  great 
exception  in  the  vast  number  of  cases,  and  its  oc- 
currence in  any  given  case  cannot  be  depended 
upon. 

In  cases  presenting  the  symptoms  above  men- 
tioned, pain,  tenderness,  deep  swelling,  or  tympan- 
ites in  the  appendix  region,  associated  with  pros- 
tration, nausea,  fever,  and  constipation,  these  phe- 
nomena coming  on  suddenly,  and  especially  where 
there  has  been  a  history  of  previous  attack, — such 
an  array  of  symptoms  would  warrant  the  diagnosis 
of  appendicitis.  When  to  these  symptoms  is  added 
a  sudden  accession  of  intense  pain  increased  on 
pressure  in  the  right  iliac  region,  with  perhaps 
moderate  pain  over  the  rest  of  the  abdomen,  a 
fluctuating  temperature  reaching  102°  or  perhaps 


24 

higlier,  slight  rigors  or  decided  chills,  moderate 
perspiration  or  decided  sweating,  and  an  increase 
of  tympany  over  the  pericsecal  region,  unquestion- 
ably there  will  be  found  pus. 

It  is  also  usual  in  abscess  formation  to  have  a 
dusky  or  sallow  skin,  an  anxious  expression,  and 
prostration. 

In  a  case  presenting  the  symptoms  of  pus,  with 
a  history  of  former  attacks  of  pain,  or  relapses,  it 
is  certain  that  we  have  to  deal  with  an  abscess,  the 
result  of  appendix  perforation. 

In  case  of  doubt,  rectal  exploration  might  be 
cautiously  resorted  to,  but,  owing  to  the  sigmoid 
flexure  being  attached  upon  the  left  side,  it  would 
only  rarely  occur  that  this  could  yield  any  positive 
information. 

In  a  small  recent  abscess  it  is  scarcely  probable 
that  it  could  be  discovered  through  the  rectum, 
while  if  the  abscess  was  large  and  encysted  there 
would  be  no  difficulty  in  detecting  it  through  the 
abdominal  walls. 

The  use  of  the  aspirating  needle  I  mention  but  to 
condemn.  It  should  never  be  used,  for,  if  it  does  not 
find  pus  we  cannot  be  sure  that  none  is  present, 
while  its  own  dangers  are  not  inconsiderable.  It  is 
in  these  cases  a  poor  and  especially  unsafe  diag- 
nostic resource. 

Differential  Diagnosis — From  Disease  of  the  Ccecum. 
— From  disease  of  the  csecum  the  diagnosis  of  ap- 
pendicitis cannot  always  be  clearly  made,  so  close  is 
their  relation ;  both  giving  rise  to  local  disturbance 
in  the  right  iliac  region. 


25 

In  the  region  under  consideration  we  have  the 
caecum  and  vermiform  appendix,  both  are  invested 
through  more  or  less  of  their  extent  with  peri- 
toneum ;  both  organs  are  subject  to  irritation,  in- 
flammation, ulceration,  and  perforation.  While  it 
is  extremely  rare  to  have  a  perforation  of  the  ccecum, 
it  is  just  the  reverse  as  to  the  appendix.  Abscess 
around  the  csecum  in  almost  every  case  is  due  to 
appendix  disease;  even  in  those  cases  where  csecal 
perforations  have  occurred  it  is  highly  probable 
that  they  may  have  resulted  from  previous  ap- 
pendix perforation  or  disease.  One  such  case  came 
under  my  observation.  On  the  second  day  after 
the  removal  of  a  gangrenous  appendix,  faeces  came 
from  the  wound  in  considerable  amount,  and  upon 
careful  inspection  two  gangrenous  perforations  were 
found  involving  the  anterior  and  lower  part  of  the 
caecum.  At  the  time  of  the  appendix-removal  the 
caecum  and  colon  were  somewhat  impacted,  and 
the  violent  inflammation  about  the  appendix  had 
extended  to  and  involved  the  intestines,  gangrene 
resulting,  due  in  part  to  contiguous  inflammation 
and  also  in  part  to  impaction.  But  if  this  abscess 
cavity  had  been  simply  opened  and  the  appendix 
not  reached,  the  subsequent  appearance  of  faeces 
would  at  once  have  established  the  diagnosis  of 
simple  caecal  perforation,  while  the  appendix  dis- 
ease would  have  been  overlooked.  So  that  in  sup- 
posed caecal  perforations,  primary  ulceration  of  the 
caecum  being  extremely  rare,  the  probability  is  that 
it  is  secondary  to  appendix  disease. 

Between  perforative  caecitis  and  perforative  ap- 


26 

pendicitis,  the  history  of  previous  attacks  of  pain 
would  make  the  diagnosis  in  favor  of  the  latter; 
even  without  the  history  of  relapsing  typhlitis,  it 
would  be  fair  to  accept  the  diagnosis  of  appendix 
disease,  for  csecal  perforations  are  exceedingly  rare 
indeed,  but  three  or  four  such  cases  have,  it  seems, 
been  reported  and  verified  by  post-mortem.  The 
necessity  for  abdominal  section  is  the  same  in  both, 
so  that  the  diagnosis  can  be  left  open  in  cases  of 
uncertainty  until  section  is  made. 

From  Acute  Intestinal  Ohsti^ciion. — A  careful  ex- 
amination of  the  patient  will  usually  exclude  fecal 
impaction,  intussusception  of  the  bowels,  internal 
strangulation,  or  volvulus.  In  ordinary  fecal  im- 
paction there  are  no  general  symptoms,  although 
there  may  be  nausea  or  vomiting;  there  is  no 
special  pain  or  tenderness,  and  the  outline  of  the 
colon  can  be  made  out  by  palpation.  There  is 
usually  a  history  of  increasing  constipation  for 
weeks  or  months  previous.  Intussusception  is 
accompanied  by  frequent  desire  to  empty  the 
bowels,  with  discharges  of  mucus  or  blood;  the 
tumor  is  sausage-shaped  and  is  not  very  tender; 
and  the  true  character  of  the  case  may  often  be  dis- 
covered by  rectal  examination.  In  volvulus  there 
is  more  pain,  but  it  is  referred  to  the  neighborhood 
of  the  umbilicus ;  there  is  neither  pain  nor  tender- 
ness in  the  iliac  region.  Strangulation  may  be 
caused  by  diverticula  and  frequently  by  constriction 
bands,  the  sequence  of  former  peritonitis.  The  in- 
testines may  be  adherent  to  the  omentum  and  be- 
come revolved  upon  it.     In  one  case  an  adherent 


"11 

appendix  vermiformis  strangulated  the  ileum.  Ob- 
struction may  also  be  simulated  by  enteritis  or 
peritonitis,  owing  to  the  paralyzing  effect  upon  the 
bowel.  When  the  obstruction  is  intestinal  the 
symptoms  advance  very  rapidly,  even  more  so  than 
in  appendicitis. 

From  Spinal  or  Perinephritic  Abscess. — Attention 
to  the  history  of  the  case  and  to  the  local  signs 
of  disorder  will  enable  us  to  diagnosticate  these 
forms  of  abscess.  The  treatment  being  almost 
identical,  at  least  as  far  as  laparotomy  is  con- 
cerned, we  need  not  waste  much  time  in  making 
refinements  of  diagnosis,  although  such  diagnosis 
can  generally  be  made.  In  the  following  case, 
it  was  not  positively  made  until  some  time  sub- 
sequent to  the  operation. 

In  !N"ovember,  1888, 1  saw  in  consultation  with  Dr. 
Bartleson,  of  Clifton  Heights,  a  young  man  twenty- 
eight  years  of  age,  who  had  been  confined  to  his  bed 
for  three  weeks,  and  presented  symptoms  of  pus 
formation  in  the  inguinal  region.  His  temperature 
fluctuated  between  100°  and  104° ;  he  had  sweatings 
and  pronounced  chills;  yet  the  pain,  which  was 
local,  was  not  severe,  but  it  was  increased  by  press- 
ure. He  had  no  history  of  former  pain  in  the 
appendix  region.  There  was,  however,  a  tumor 
which  could  readily  be  made  out,  but  at  a  consider- 
able depth  :  I  decided  to  explore  this  by  operation. 
Incision  opened  into  an  abscess,  but  the  cavity 
seemed  closed,  and  it  was  not  so  deep  as  I  had 
usually  found  in  suppurative  appendicitis.  N"either 
the  caecum  nor  the  appendix  came  into  view,  nor 


28 

could  they  be  found  in  the  cavity  or  its  borders. 
The  pus-cavity  was  drained,  and  subsequently 
closed.  The  case  subsequently  proved  to  be  one 
of  psoas  abscess,  originating  in  the  lumbar  verte- 
brae, but  no  positive  diagnosis  could  be  made  for 
several  months  after  operation,  by  which,  neverthe- 
less, he  was  completely  cured  of  both  abscess  and 
the  spondylitis. 

In  psoas  abscess,  especially  in  young  children, 
some  difficulty  may  be  experienced,  at  times,  in 
differentiating  it  from  pericsecal  inflammation.  But 
in  the  former  there  is  generally  a  history  of  long- 
present  ill-health  and  pain  in  the  dorsal  region, 
usually  with  symptoms  of  vertebral  disease  (z.e., 
gastric  irritation,  intercostal  pains,  constriction 
band,  or  pains  in  the  thighs).  The  pains  are 
colicky  and  associated  with  flatulence;  and  there 
is  more  or  less  pain  or  irritation  of  the  bladder. 
Abscess  from  disease  of  bodies  of  the  spine  generally 
points  in  the  groin,  either  just  above  or  below 
Poupart's  ligament ;  it  is  associated  with  a  history 
of  ill-health,  and  difficulty  in  walking.  Iliac  ab- 
scess may  occur  unconnected  with  the  spine  or 
cgecum,  arising  within  the  abdominal  cavity  near 
the  spine.  In  such  cases  the  symptoms  of  systemic 
disturbance  are  quite  decided:  chill,  more  or  less 
pronounced,  with  hectic  fever  and  night-sweating 
are  very  apt  to  occur.  As  soon  as  the  existence 
of  pus  is  recognized,  an  exploratory  incision  should 
be  made  in  order  to  detect  the  source  if  possible. 

Tumors  may  appear  in  this  region,  both  malignant 
and  non-malignant,  and  their  nature  may  be  in- 


29 

ferred  from  their  physical  characters  and  the  clini- 
cal history,  which  shows  their  gradual  increase  in 
size,  etc. 

The  history  of  the  mode  of  onset  or  invasion 
of  the  disease  will  be  of  service  in  making  its  diag- 
nosis. Strangulation  of  the  bowel,  intussuscep- 
tion, peritonitis,  volvulus,  generally  come  on  very 
suddenly.  Impaction  of  faeces,  psoas  or  iliac  ab- 
scess, and  tumors  come  on  gradually.  Csecitis 
and  perforative  ulcer  of  the  caecum  are  also  more 
or  less  rapid  in  their  course,  and  point  superficially 
more  quickly  than  does  the  abscess  to  which  appen- 
dicitis gives  rise. 

Treatment. — The  treatment  of  pericsecal  inflam- 
mation, no  matter  whether  its  origin  is  in  or  about 
the  caecum  or  in  the  appendix,  may  be  divided  into 
two  divisions :  that  of  the  pre-purulent  and  that  of 
the  post- purulent  stage ;  or,  first,  before  formation 
of  pus  or  of  appendix-perforation ;  and,  secondly, 
after  that  event. 

The  treatment  of  the  pre-purulent,  irritative, 
catarrhal,  or  simple  inflammatory  disorders  of  the 
caecum,  its  surroundings,  or  the  appendix,  should 
consist  in  absolute  rest  in  bed,  restriction  of  diet  to 
nourishing  liquids,  hot  poultices  or  fomentations 
frequently  replaced  upon  the  parts,  perhaps  local 
depletion,  and  possibly  the  hypodermic  exhibition 
of  morphine  to  control  pain;  while  the  bowels 
should  be  kept  open  and  free  from  accumulations 
of  gas  and  faeces  by  the  administration  of  calomel 
or  salines  and  enemas. 

Prompt  resolution  should   take  place   in  cases 


30 

which  are  not  to  go  on  to  the  stage  of  pus-forma- 
tion. Tedious  recovery,  relapse,  or  recurrence  of 
symptoms,  would  point  to  the  probable  presence  of 
conditions  exceedingly  dangerous  to  the  patient 
from  the  liability  to  general  peritonitis  or  perfora- 
tion at  any  time,  and  further,  they  would  point,  as 
a  rule,  to  the  appendix  as  the  source  of  irritation 
and  danger. 

That  treatment  of  pericsecal  inflammation  which 
places  the  bowels  "  at  rest"  from  the  start,  or  in 
"  splints,"  commonly  so  called,  has  probably  been 
the  cause  of  more  serious,  often  fatal,  results  than 
can  well  be  estimated.  The  use  of  opium  without 
question  masks  the  symptoms  which  indicate  pus- 
formation,  causing  loss  of  diagnostic  symptoms  and 
of  valuable  time  at  a  most  critical  period ;  the 
apparent  improvement  due  to  lack  of  pain,  often 
causing  postponement  of  operative  interference 
until  the  patient  is  practically  in  a  hopeless  con- 
dition. Intense  pain  is  more  often  an  indication 
for  operation  than  for  morphine;  the  knife  will 
remove  both  pain  and  danger  and  give  radical 
relief  for  all  time,  as  recurrence  cannot  occur  when 
the  cause  of  the  malady,  the  appendix,  has  been 
removed. 

In  the  second  division,  the  process  has  gone  be- 
yond the  simple  irritative  or  inflammatory  stage  and 
pus  has  formed. 

Pus  in  contact  with,  or  in  the  cavity  of,  the 
peritoneum  (and  such  is  precisely  the  situation  in 
abscess  surrounding  the  appendix  or  caecum)  is 
vastly  more  serious  than  would  be  an  abdominal 


31 

section  for  its  relief.  So,  the  diagnosis  of  pus 
having  been  made,  apd,  indeed,  often  without  posi- 
tive diagnosis,  operation  is  positively  indicated ; 
many  other  risks  are  to  be  taken  rather  than  those 
of  general  purulent  peritonitis,  for  early  interfer- 
ence will  save  almost  if  not  all  cases  from  this 
much-dreaded  complication,  while  the  danger  of 
operation  becomes  slight  compared  with  that  of 
general  abdominal  inflammation. 

Local  or  general  peritonitis  supervening  in  a 
person  who  has  a  history  of  caecal  trouble  would 
more  than  justify  operation. 

At  a  later,  or  even,  perhaps,  in  the  chronic  stage  of 
the  disorder,  all  available  diagnostic  skill  must  be 
exerted  when  pericsecal  abscess  may  have  pointed  in 
an  anomalous  situation,  and  we  must  ever  adhere 
to  the  modern  surgical  rule,  always  to  attack  pus 
at  its  source  if  possible.  When  the  caecum  is  nor- 
mally placed,  this  is  always  feasible,  if  the  disease 
be  recognized. 

Preparation  for  the  Operation. — There  is  generally, 
from  the  very  nature  of  the  case,  very  little  time 
for  any  special  preparatory  treatment. 

The  field  of  operation  should  be  made  clean  with 
soap  and  water,  then  shaved,  washed  with  ether  or 
turpentine,  soapsuds  again,  and  then  douched  with 
a  mercuric  bichloride  solution  (1  to  1000) ;  the  um- 
bilicus having  been  carefully  cleansed  and  its  cavity 
rubbed  with  iodoform. 

If  possible,  the  disinfecting  process  should  be 
completed  some  hours  before,  and  the  abdomen 
kept  covered  with  a  wet  bichloride  dressing.     The 


32 

field  of  operation  should  be  protected  by  towels 
wrung  out  of  hot  mercuric  solution. 

The  instruments  should  be  treated  by  boiling, 
and  then  kept  in  a  three-per-cent.  carbolic  acid  so- 
lution, or  used  from  cooled  boiled  water. 

The  operator  and  his  assistant — one  is  sufficient — 
should  likewise  observe  the  rules  of  strict  antisepsis, 
which  should  rigidly  prevail  throughout. 

Operation. — The  line  of  abdominal  incision  should 
be  lateral,  not  median.  The  advantages  of  the  for- 
mer are  very  obvious  and  positive.  It  is  made  di- 
rectly over  the  appendix  region  and  abscess  cavity. 
If  a  median  incision  were  made  the  peritoneal  cavity 
would  not  only  be  often  needlessly  opened,  but  the 
section  would  be  at  a  point  remote  from  the  caecum 
and  appendix,  in  a  position  in  which  they  cannot 
well  be  reached.  Indeed,  it  would  often  be  quite 
impossible  to  deal  with  a  diseased  appendix  unless 
the  incision  were  lateral,  for  the  difficulties  ex- 
perienced in  bringing  into  view  and  separating 
this  organ  when  it  is  firmly  bound  by  adhesions  to 
the  caecum,  as  is  often  the  case,  are  not  inconsider- 
able. If  pus  have  gained  access  to  the  peritoneal 
cavity,  or  the  intestines  come  to  view,  thorough 
cleansing  can  be  effected  as  well  by  a  lateral  in- 
cision, while  the  sloughs  of  cellular  and  other 
tissues,  which  always  may  be  expected  from  the 
abscess  cavity  and  surrounding  parts,  can  more 
readily  discharge  through  an  opening  contiguous 
to  the  disease. 

Usually  there  occurs  within  a  few  hours  after 
operation  great  swelling  of  the  wound   and  ileo- 


33 

csecal  region.  This  requires  removal  of  the  sutures ; 
the  wound  gapes  and  the  caecum  is  fully  exposed, 
but  the  latter  is  held  naturally  in  position,  and 
there  is  no  danger  from  intestinal  protrusion; 
drainage  by  such  a  free  opening  is  proportionally 
favored. 

The  incision  should  be  from  four  to  six  inches  in 
length  and  correspond  with  the  appendix  region ; 
it  should  extend  from  an  inch  above  the  middle  of 
Poupart's  ligament  upward  through  the  right  linea 
semilunaris  and  down  until  peritoneum,  csecum, 
or  pus  is  reached.  Occasionally  pus  is  not  dis- 
covered until  the  caecum  is  displaced,  when  the 
abscess  cavity  and  the  appendix  come  in  view. 
Bleeding  should  be  arrested  by  the  use  of  haemo- 
static forceps  and  the  application  of  hot  water. 

I  have  found  that  the  appendix  is  normally 
situated  immediately  under  a  point  two  inches  dis- 
tant from  the  right  anterior  superior  iliac  spinous 
process,  on  a  horizontal  line  drawn  from  this  pro- 
cess towards  the  median  line  of  the  body,  so  that 
this  incision  is  directly  over  the  organ.  When  the 
abscess  cavity  is  reached,  gas  may  be  first  discharged, 
then,  when  pus,  which  is  always  offensive,  has  been 
reached  and  sponged  or  washed  away,  the  appen- 
dix is  found  either  lying  free  or  attached  to  the 
caecum  or  abscess  wall.  It  is  not  always  an  easy 
matter  to  distinguish  the  appendix ;  on  one  occasion 
this  organ  and  an  epiploic  appendage,  both  of  the 
same  size,  and  resembling  each  other  in  general  ap- 
pearance, were  side  by  side  and  both  firmly  glued 
to  the  caecum.      The  most  inferior  of  these  bodies 


34 

was  correctly  judged  to  be  the  appendix.  The 
anatomical  relations  will  always  differentiate  the 
appendix. 

Irrigation  with  recently  boiled  or  distilled  water 
at  a  temperature  of  105°  to  110°  gives  a  clear  view  of 
the  surroundings  of  the  caecum  and  its  appendix ;  at 
this  time  it  may  be  necessary  to  enlarge  the  wound 
in  order  to  obtain  sufficient  space  to  conduct  the 
necessary  manipulations ;  this  will  be  found  es- 
pecially indicated  when  the  appendix  is  more  or 
less  firmly  glued  to  intestine. 

The  appendix  is  practically  always  found  to  be 
the  seat  of  trouble ;  in  any  case  it  should  be  ex- 
cised,— unquestionably  so  if  swollen,  inflammed, 
perforated,  containing  masses  of  faeces,  or  harbor- 
ing foreign  bodies. 

The  removal  of  the  appendix  after  gently  freeing 
it  from  any  adhesions  which  it  may  have  formed 
can  best  be  accomplished  by  ligaturing  it  close  to  its 
csecal  attachment  with  a  silk  ligature,  and  excising 
it  just  outside  the  point  of  ligation.  If  the  general 
peritoneal  cavity  has  not  been  involved  by  the  ab- 
scess nor  during  the  necessary  manipulations  of  ex- 
cising the  appendix,  the  abscess  cavity  should  simply 
be  washed  out  with  a  mercuric  chloride  solution  (1 
to  1000),  and  a  good-sized  rubber  drainage-tube 
carried  to  the  bottom  of  the  cavity,  and  brought 
out  near  the  most  dependent  part  of  the  wound. 
In  all  of  the  cases  which  have  come  under  my 
care  the  peritoneal  cavity  has  been  invaded  by  pus, 
either  before  or  during  the  operation,  so  that  the 
entire    abdominal   cavity   had    to   be    thoroughly 


35 

cleansed  and  drained.  Irrigation  of  the  abdomi- 
nal cavity  can  best  be  accomplished  by  a  fountain 
(or  other  form  of)  syringe,  carrying  sterilized 
water  of  a  temperature  of  105°  to  110°.  Every 
part  of  the  abdominal  cavity  should  be  thoroughly 
and  repeatedly  drenched  if  pus  has  entered  it. 

Should  far-advanced  peritonitis  be  found,  the  in- 
testines must  be  withdrawn,  and  all  adhesions  parted 
with  the  finger  or  knife  during  the  process  of 
cleansing  and  before  they  are  returned  to  the  peri- 
toneal cavity. 

In  any  abscess  of  the  ileo-csecal  region  we  should 
always  suspect  appendix  disease,  and  an  effort  should 
always  be  made  to  expose  this  organ.  In  no  case 
should  a  simple  evacuation  of  pus  be  considered 
sufficient,  especially  if  the  history  of  the  case  pre- 
sented any  account  of  probable,  former  appendix 
trouble.  A  case  of  this  character  came  under  my 
care,  in  which  at  first,  in  1885,  I  simply  evacuated 
an  abscess  situated  in  the  ileo-caecal  region,  and 
made  no  investigation  of  the  appendix,  as  the  ab- 
scess cavity  seemed  a  closed  one.  Three  years 
later  I  was  obliged  to  make  abdominal  section  and 
remove  a  diseased  appendix,  which  undoubtedly 
had  existed  at  the  time  of  the  first  operation. 

Csecal  perforations  should  be  cleansed,  curetted, 
and  closed  by  Lembert  suture.  If  this  be  difficult 
or  impracticable  from  the  position  of  the  perfora- 
tion or  otherwise,  no  danger  need  be  apprehended, 
for  such  fistules  close  naturally ;  one  such  compli- 
cation occurred  in  a  case  in  which  I  excised  a 
sloughing   appendix.      At  the   time   of  operation 


36 

the  csecum  seemed  somewhat  distended  and  its 
color  unnaturally  dark ;  forty-eight  hours  after- 
wards fseces  were  observed  in  the  wound,  which 
was  sufficiently  open  to  see  a  gangrenous  perfora- 
tion ;  the  fistule  gradually  contracted,  but  continued 
discharging  a  small  amount  of  intestinal  contents 
for  some  months,  when  it  permanently  closed  of 
its  own  accord. 

If  the  inflammation  should  be  found  in  the  caecum 
itself,  due  to  the  presence  of  a  foreign  body  or  to 
impaction  of  the  faeces,  they  should  be  either  ex- 
cised or  urged  by  prudent  force  along  the  bowel. 

In  their  operative  removal  a  simple  incision,  after- 
wards united  by  Lembert  sutures,  would  answer 
every  purpose. 

When  the  general  peritoneal  cavity  has  been  in- 
volved by  the  abscess,  or  broken  into  during  opera- 
tion, it  requires,  after  cleansing,  to  be  drained,  and 
for  this  purpose  a  large,  glass,  perforated  tube, 
slightly  curved  (Keith's)  is  carried  down  between 
the  coils  of  intestines  to  the  most  dependent  part 
of  the  pelvic  cavity  and  allowed  to  emerge  at  a 
convenient  point  near  the  lower  part  of  the  wound. 
It  is  safer  in  all  cases  also  to  insert  a  perforated 
rubber  drain  to  the  bottom  of  the  abscess  cavity. 
The  wound  is  then  brought  together  by  interrupted 
silk  sutures. 

A  piece  of  protective  tissue  perforated  for  the 
tube  exit  is  then  applied  to  the  wound.  To  the 
bottom  of  the  glass  tube  is  carried  a  cotton  rope 
which  absorbs  the  secretions,  and  over  its  outlet 
a  wad  of  cotton  is  placed  and  enveloped  in  rubber 


37 

tissue  in  the  usual  manner.  Iodoform  is  now  dusted 
over  the  wound  surroundings  and  a  large  dressing 
of  wet  bichloride  gauze  and  cotton  is  then  applied 
and  held  in  position  by  a  four-tailed  flannel  binder. 

Post- Operative  Treatment. — After  the  effects  of  the 
anaesthetic  have  passed  off,  a  hypodermic  injection 
of  morphine  may  be  required  to  relieve  pain,  or 
check  vomiting  or  restlessness.  The  ordinary  rules 
of  abdominal  surgery  are  to  be  observed.  The 
cotton  rope  should  frequently  be  changed,  gener- 
ally every  three  hours  is  sufficient  for  the  first  few 
days ;  before  it  is  replaced  the  tube  should  be  irri- 
gated with  boiled  or  distilled  water,  peroxide  of 
hydrogen,  or  weak  carbolic-acid  solution,  especially 
when,  as  is  often  the  case  at  first,  the  secretions  are 
more  or  less  offensive. 

Milk  should  be  given  at  short  intervals,  and  in 
small  doses,  and  stimulants  are,  as  a  rule,  early  re- 
quired ;  if  there  has  been  much  exhaustion  cham- 
pagne should  be  freely  given. 

It  is  important  that  the  bowels  should  be  promptly 
opened  and  kept  so;  and  for  this  purpose  small 
doses  of  calomel  should  be  given,  say  -^^  or  ^  of 
a  grain  hourly  or  half-hourly,  with  an  occasional 
^-grain  dose  of  podophyllin ;  after  this  salines  can 
be  substituted.  Quinine  and  the  malt  extracts  are 
strongly  indicated.  Opium  should  not  be  used  in 
any  form  internally ;  morphine  in  small  doses  hypo- 
dermically  rarely  may  be  required  subsequent  to 
operation  to  relieve  pain  or  restlessness,  but  should 
be  regarded  as  a  dangerous  agent  and  used  with  great 
reluctance. 


It  will  usually  be  found  that  tlie  cellular  tissues 
surrounding  the  abscess  are  hopelessly  infected  and 
necrotic,  perhaps  for  a  long  distance  ;  it  will  like- 
wise be  found  impossible  adequately  to  remove  or 
cleanse  them.  Hence  the  wound  will  almost  in- 
variably run  a  foul  septic  course,  great  sloughs  will 
keep  coming  away  for  many  days,  and  it  will  event- 
ually, in  from  six  to  eight  weeks,  heal  firmly  from 
the  bottom  by  granulation  and  cicatrization.  I 
have  advised,  nevertheless,  that  the  wound  always 
be  primarily  sutured,  for  by  so  doing  and  subse- 
quently cutting  suture  after  suture  as  the  wound 
becomes  tense,  we  secure  an  anchorage  of  the 
caecum  in  the  bottom  of  the  wound  by  lymph  exu- 
date which  prevents  prolapse  or  hernia  subsequent 
to  cutting  the  sutures,  or  after  cicatrization. 

As  a  rule,  one  or  two  sutures  must  be  cut  at  the 
end  of  twenty  hours,  others  subsequently  as  ten- 
sion may  demand.  When  these  are  cut  the  already 
anchored  caecum,  and  perhaps  other  intestines,  come 
into  view  as  the  wound  widely  gapes,  but  they  show 
no  tendency  to  prolapse  even  when  the  patient 
strains  or  coughs,  although  the  latter — indeed  all 
active  motions — are  to  be  strenuously  avoided. 

The  gaping  wound  should  be  packed  with  strips 
of  gauze,  which  are  to  be  frequently  changed  and  the 
parts  cleansed  with  peroxide  of  hydrogen  until  the 
tubes  are  away  and  the  granulations  approach  the 
surface,  then  adhesive  straps  are  used  to  approxi- 
mate the  wound  edges.  A  binder,  or  good  abdomi- 
nal belt,  must  be  worn  for  six  months  or  a  year 
after  complete  closure  of  the  wound. 


39 

Symptoms  of  periioniiis  after  operation  should  be 
met  by  free  saline  purgation  (Epsom  salts  hourly  or 
half  hourly)  or  by  reopening  and  washing  out  the 
abdomen. 

The  time  for  the  removal  of  the  glass  pelvic 
drain  vrill  depend  altogether  upon  the  amount  and 
character  of  the  secretion ;  usually  it  can  be  dis- 
pensed with  by  the  fifth  or  sixth  day,  but  frequently 
is  retained  until  the  tenth  or  twelfth.  It  is  com- 
monly forced  out  by  the  action  of  the  intestines  at 
the  proper  time.  When  it  is  removed,  it  is  well  to 
introduce  in  its  place  a  small  rubber  drain,  which 
can  be  each  day  brought  nearer  the  surface  and 
then  cut  away  piecemeal. 

The  dressings  should  be  replaced  as  often  as  they 
become  soiled,  and  this  is  generally  every  six  or 
eight  hours  for  the  first  few  days,  afterwards  at 
longer  intervals. 

I  have  thus  gone  over,  in  a  more  or  less  brief 
manner,  the  symptoms  which  should  guide  in  mak- 
ing the  diagnosis  of  appendicitis  and  pus  formation 
in  or  about  the  pericsecal  region,  and  have  presented 
in  as  strong  a  manner  as  possible  the  necessity,  in 
such  event,  for  early  operative  interference. 

The  details  of  the  operation  and  post-operative 
treatment  have  been  given  with  some  minuteness, 
and  this  seems  proper,  because  such  specific  direc- 
tions have  not  been  published. 

In  conclusion  it  may  be  said  that  although  ab- 
dominal surgery  can  show  many  brilliant  achieve- 
ments, yet  scarcely  in  any  other  instance  does  an 


40 

operation  so  completely  afford  its  own  justification, 
or,  when  properly  timed,  present  such  satisfactory 
results,  as  laparotomy  when  performed  for  perfora- 
tive appendicitis. 


adde:n'dum. 

The  preceding  paper,  it  will  be  observed,  has  been 
confined  strictly  to  a  consideration  of  acute  forms 
of  appendicitis.  It  is  proposed  in  this  additional 
note  to  consider  in  brief  the  subject  of  surgical 
interference  with  chronic  appendicitis  and  those 
conditions  which  give  rise  thereto. 

I  have  long  been  an  advocate  for  removal  of  the 
diseased  appendix  in  the  interval  between  acute 
attacks ;  indeed,  so  long  ago  as  in  my  first  writing 
upon  this  topic,  I  urged  that  recurring  attacks  of 
appendicitis  or  perityphlitis  should  be  considered 
an  absolute  indication  for  removal  of  the  appen- 
dix ;  preferably  after  entire  subsidence  of  an  acute 
paroxysm,  when  every  condition  is  so  much  more 
conducive  to  prompt  recovery,  and  primary  heal- 
ing of  the  wound.  I  would  now  again  aver  that  re- 
curring attacks,  or  persistent  chronic  appendicitis, 
whether  due  to  protraction  in  milder  degree  of  the 
acute  seizure  or  even  originating  and  continuing 
without  intercurrent  acute  attacks,  not  only  jus- 
tify operation,  but  absolutely  demand  excision  of 
the  appendix  to  insure  the  future  safety  of  the 
patient.  For  it  must  now  be  acknowledged  that 
recurring   attacks  of  appendicitis   usually,  sooner 


41 

or  later,  eventuate  in  that  most  dangerous  of  acute 
affections,  perforatio-n  of  the  organ  and  pericsecal 
abscess,  which,  as  likely  as  not,  will  take  place  when 
the  person  is  situated  where  adequate  medical  re- 
lief cannot  be  had.  How  much  better,  then,  to 
place  him  at  once  and  for  all  time  beyond  the  possi- 
bility of  danger  from  this  source,  by  a  compara- 
tively trivial  operation  at  a  time  and  under  con- 
ditions when  prompt  and  permanent  relief  and 
recovery  can  almost  invariably  be  secured ! 

A  study  of  the  pathology  of  appendix  disease 
shows  that  many  cases  commence  as  ulcerations 
of  the  mucous  membrane  of  the  appendix,  which, 
with  or  without  the  formation  and  presence  of  con- 
cretions, progress  to  perforation,  and,  in  either  case, 
originate  symptoms  of  intermittent  or  continuous 
chronic — perhaps  disabling — appendix  inflamma- 
tion ;  and,  earlier  or  later,  either  in  the  primary  or 
a  subsequent  attack,  give  rise  to  perforation,  abscess, 
and,  when  improperly  dealt  with,  to  death. 

I  would,  then,  reiterate  my  belief  that  symptoms 
of  continuing  appendix  disease,  whether  continuing 
after  acute  attack,  or  due  to  primarily  chronic 
disease,  or  simply  indicative  of  ulceration  of  the 
lining  mucous  membrane  of  the  appendix,  invaria- 
bly demand  excision  of  the  offending  organ. 

All  of  the  various  distressing  and  often  disabling 
symptoms  of  the  various  appendicular  disorders, 
including  those  arising  from  inflammatory  adhe- 
sions of  the  organ  to  neighboring  viscera,  are  re- 
lieved, as  if  by  magic,  by  excision  of  the  appendix. 
This  has  been  amply  proved  by  the  brilliant  cases 


42 

of  Treves,  Senn,  Hoegh  of  Minneapolis,  Bernardy, 
and  Shober  of  Philadelphia. 

Operation  for  Chronic  Appmdix  Disease.  —  The 
premeditated  operation  permits  the  careful  prepa- 
ration of  the  patient  beforehand  by  rest  in  bed, 
regulated  diet  and  bowels,  and  thorough  general 
and  local  disinfection. 

Incision  should  be  made  directly  over  and  carried 
down  through  the  right  linea  semilunaris.  It 
should  be  at  least  three  inches  in  extent  and  should 
be  enlarged  as  may  be  required  for  necessary  manip- 
ulation. After  the  peritoneum  has  been  exposed  to 
the  full  length  of  incision,  all  bleeding  points  are 
carefully  ligatured  with  fine  catgut  and  the  wound  is 
sponged  entirely  free  of  blood  or  other  fluid.  I^ow 
the  peritoneum  is  incised.  If  the  appendix  does 
not  at  once  present  in  the  wound  it  will  be  neces- 
sary to  press  the  intestine  upward  with  the  finger. 
If,  as  may  happen,  the  appendix  is  found  to  be 
partially  or  wholly  attached  to  the  csecum  or  else- 
where, the  adhesions  must  be  separated  by  the 
finger,  or,  if  strong,  be  divided  between  double 
ligatures.  The  appendix  may  be  entirely  free  of 
mesentery  or  the  latter  may  extend  throughout 
its  whole  extent;  if  so,  this,  as  it  were,  meso- 
appendix  must  be  ligatured  in  portions  and  cut 
through  between  the  ligatures  and  the  appendix. 
The  latter  organ  is  then  included  in  a  ligature  at 
its  caecal  origin  and  cut  off". 

A  number  of  methods  have  been  adopted  for 
dealing  with  the  resulting  stump  of  the  appendix. 
If  it  is  to  remain  projecting  from  the  caecum,  the 


43 

csecal  peritoneum  should  be  brought  over  it  and 
there  united  by  Lembert  sutures. 

Although  I  have  had  no  experience  in  the  re- 
moval of  the  appendix  for  chronic  disease,  yet,  from 
experiments  made  upon  the  cadaver  with  a  view  of 
getting  entirely  rid  of  the  stump  and  hence  of  all 
subsequent  danger  from  it,  I  have  found  that  it  can 
very  readily  be  inverted  and  completely  invaginated 
into  the  csecal  cavity. 

The  proposed  manipulation  consists,  after  ligatur- 
ing and  cutting  away  the  appendix,  in  grasping  the 
stump  at  its  distal  extremity  with  forceps  and  push- 
ing it  into  the  caecum ;  the  peritoneum  is  then  ap- 
proximated over  the  inverted  stump  by  means  of 
three  or  four  Lembert  sutures  which  retain  it  in 
the  caecum,  and  effectuall}^  prevent  its  subsequent 
prolapse. 

This  is  easily  accomplished,  and  absolutely  re- 
moves all  source  of  danger  from  any  future  irrita- 
tion in  the  cul-de-sac  or  that  part  of  the  appendix 
between  the  point  of  ligation  and  the  caecum.  After 
the  parietal  wound  has  been  carefully  sponged  and 
all  clots  removed,  it  is  brought  together  by  two  rows 
of  interrupted  sutures, — a  deep  set  for  the  closure  of 
the  peritoneum,  and  a  superficial  series  to  unite  the 
edges  of  the  external  or  skin-and-muscle  wound. 
Drainage  is  not  necessary  unless  under  very  ex- 
ceptional circumstances.  The  external  wound  is 
to  be  dressed  after  the  usual  method,  as  previously 
described. 

The  diet  for  the  first  few  days  should  be  con- 
fined to  liquids,  especially  milk,  often  and  in  small 


44 

quantities.  The  bowels  (which  are  supposed  to 
have  been  opened  well  upon  the  morning  of  opera- 
tion) need  not  be  disturbed  for  two  or  three  days, 
when  they  should  be  stimulated  to  gentle  activity 
by  mild  mercurial  or  saline  laxatives.  The  dress- 
ings need  not  be  disturbed  for  a  week  or  ten  days, 
when  the  sutures — if  of  silk — should  be  removed. 
A  supporting  binder  or  abdominal  belt  should  be 
worn  until  the  cicatrix  is  quite  firm. 


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